We in the palliative community have learned through painful experiences that there are no shortcuts when end-of-life decisions need to be made. There are no quick fixes to decide about a feeding tube or about discontinuing care or considering hospice.
One highly effective way to address the issue of how aggressively to continue care is with a family conference (with or without the patient present).
During the meeting, typically a cascade of feelings and emotions and often hidden agendas come tumbling out among multiple family members. At the end of the meeting, a bottom line is quite clear when the answer to this question is considered: “What is the best decision for the patient’s well-being, rather than what decision do I, as a family member, want for the patient?”
Ah, but what happens when wife number one wants the respirator turned off (“Enough is enough”), and wife number two demands a full court medical press?
Without guidance from an advance directive, and if the patient does not have capacity to decide and has not appointed a healthcare surrogate, then family conflict about the course of treatment quickly becomes quarrelsome.
In these cases, we gather the family and medical team and have a clear discussion about milestones that need to be reached to tell us about the relative futility of continuing some of these medical interventions. (Milestones include weight gain, ability to be awake more hours of the day, increasing ability to get out of bed, for examples.)
If you are faced with these types of agonizing decisions, it’s important to engage the patient, if able, in these discussions so that there is complete transparency of the decision-making process. I’m reminded of the all-too-typical scenario where we on the care team have a serious end-of-life discussion around the bedside with the patient and the family. We then walk into the hallway and are followed by a parade of family members who say, “Okay, Doc, tell me what’s really going on.”
When this occurs, the medical team respectfully returns to the room so that the patient understands there are no “hidden deals” and all the facts are clearly on the table.
We on the medical team give our patients our best advice and work with the patients to honor their wishes and guide the next treatment step (knowing that sometimes that next step may be no treatment at all). But when family members speak for the patient and disagree and bring belligerence and aggression to the family meeting, those of us in the white coats find it very difficult to work in these situations.
I will confide this to you: We often push back in these confrontational settings. Not that we’d go along with another MRI just because Junior plays doctor and thinks Dad needs one, but we cringe in horror at the family dynamics, the one-upping, and choose to remove ourselves from the soap opera playing out over the deathbed.
Time is better spent talking with Dad about his hopes and expectations, relieving his pain and suffering, and not indulging a know-it-all kid (or adult) with a laptop and Wi-Fi.
Edward T. Creagan, MD, a cancer specialist, is the first Mayo Clinic doctor board certified in hospice and palliative medicine. His new book, Farewell: Vital End-of-Life Questions and Candid Answers, is about navigating those precious last days, at the bedside, and saying farewell with hope, love, and compassion. For more, go to www.AskDoctorEd.com.